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Safety Culture Introduction
IAEA Safety Culture Introduction “The Dot Talk”
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Work as Imagined Vs. Work in Practice
Normally Successful!
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Drift and Accumulation*
Expectations SAFETY Drift (from work as Imagined) Current Practice Real Margin for Error Error Accumulation (of hidden hazards) DANGER TIME *Adapted from S. Dekker, Resilience Engineering, 2006
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Laboratory Safety Programs…
Hmmmm….. Two Ways To Understand Laboratory Safety Programs…
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System Optimism – Need for Control
Things go right because: Systems are well designed and maintained, Designers can foresee and anticipate every contingency Procedures are complete and correct People behave as they are expected to — as they are taught Therefore, humans are a liability and performance variability is a threat.
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System Realism Things go right because people:
Learn to overcome design flaws and functional glitches Adapt their performance to meet demands Interpret and apply procedures to match conditions Can detect and correct when things go wrong Therefore, humans are an asset without which the proper functioning of the systems would be impossible.
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To deviate is also human …
To err is human … To deviate is also human … People are outcome-based and value immediate and certain results They make decisions to achieve the desired results As they try to do more with less, they drift away from expected behaviors
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Unexpected Combinations of Normal Variability
Accidents as… Unexpected Combinations of Normal Variability We must strive to understand that accidents don’t happen because people gamble and lose. Accidents happen because the person believes that what is about to happen is not possible… or what is about to happen has no connection to what they are doing… or, that the possibility of getting the intended outcome is well worth whatever risk there is. Erik Hollnagel
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Resilience Resilience: The worker (or organization’s) ability to adjust its functioning to sustain operations during unexpected conditions and in the face of escalating demands, disturbances, and unforeseen circumstances… Engineering for Resilience – the tools that promote resilience that: anticipate, monitor, respond, learn
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On Culture What is Culture?
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Schein Model Actions Observable Non-observable Values Beliefs/
Assumptions
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Culture is to an Organization what Memory is to Individuals
Using Schein’s Ideas: Culture emerges in adaptive interactions Culture consists of shared elements Culture is transmitted across time and generations Culture is Deep Culture is Broad Culture is Stable
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Three Evolutions of the Development of a Safety Culture
Safety is Based on Rules and Regulations Safety is Considered an Organizational Goal Safety Can ALWAYS be Improved
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IAEA Evolutions of Safety Performance: A Predictive Maturation Model
3. Learning Organization HRO 2. Conduct of… phase 1. Compliance-based Safety Leadership
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Safety is Based on Rules and Regulations
Compliance-Based Model Problems are not anticipated – organizations react Communication between departments is poor Low collaboration / Low shared decision-making People are named, blamed, shamed, and retrained Management is seen as enforcement People are rewarded for obedience and results
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Safety is Considered an Organizational Goal
The Conduct Of…. Model Know that culture is there – and worried about it No clue why added controls and training don’t work Management’s response to mistakes is more procedures Organization is interested in learning externally People / technology interface is valued only for efficiency People are rewarded for meeting (exceeding) goals No attention paid to long-term consequences
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Safety Can ALWAYS be Improved
Learning Organization (HRO) Model Problems are anticipated – event prevention practiced Inter-departmental collaboration is strong and normal No conflict between safety and production goals Management is present during safety decisions Learn from others, both internally and externally People are rewarded for improving process and results
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IAEA Evolutions of Safety Performance: A Predictive Maturation Model
3. Learning Organization HRO 2. Conduct of… phase 1. Compliance-based Safety Leadership
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On Organizational System
Only people hold this patchwork of processes together in reality People are necessary to create safety through practice There are always multiple goals in conflict In pressurized systems, right decisions do not always get made. Systems as a norm are reliable and dependable – we can normally depend on these systems so that when we trade off risk for doing work we can rely on the system filling in the blanks.
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IAEA Safety Culture Principles
Safety is a universally recognized value Leadership for safety is clear and understood Accountability for safety is clear and moves upward Safety is integrated in all activities Safety is learning driven
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Old vs. New View of Human Error
Human error is a cause of accidents To explain failure, investigations must seek failure They must find people’s inaccurate assessments, wrong decisions and bad judgments Human error is a symptom of trouble deeper inside a system… To explain failure, do not try to find where people went wrong. Instead, find how people’s assessments and actions made sense at the time, given the circumstances that surrounded them.
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The Sterigenics Event
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Condition/Error Characteristics
Active Errors change equipment, system or processes that trigger immediate undesired consequences. In other words an Active Error has immediate consequences and you know who did it. Latent Conditions result in undetected organization-related weaknesses or equipment flaws that lie dormant.
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Understanding Events Incentives are the cornerstone of human behavior
Dramatic events often have distant even subtle causes Conventional wisdom is often wrong “Not everything that can be counted counts and not everything that counts can be counted.”
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Process Complexity Complex systems have a strong tendency to move incrementally toward unsafe operations Human errors become more complex when systems become more complex With increased complexity, more unanticipated situations exist More encounters in which procedures are non-optimal or non-workable
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Purpose of Procedures? Achieve success or Avoid failure
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The Complexity Conundrum
In highly complex processes – there will be more errors (because of the complexity of the process) – However, highly complex processes have much less tolerance for error.
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Anatomy of an Event (A Failure Model)
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13 Basic Human Behavior Tenets
People do what they’ve done before People do what they see others do People don’t do what they can’t do Behavior is a function of organizational structure and processes Behavior is elicited by past experience Reinforcement increases frequency of behaviors Reinforcement works until it saturates Punishment decreases frequency of behaviors Punishment elicits only the avoidance if consequences Avoidance behaviors can’t EVER be managed Silence is punishment for functional behavior Silence is reinforcement for dysfunctional behavior How my manager responds to events tells me EVERYTHING about my manager
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Action Planning Goal Statement/Problem Statement Actions Needed
Barriers to Success – Consequences (intended/unintended) What should we be doing, starting tomorrow, to make this happen
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A History The Concept of Safety Culture was First Introduced by the International Nuclear Safety Advisory Group in INSAG – 4 Report, Written in 1991. Safety Culture was identified as a Fundamental Management Principle IAEA’s Journey Began with Four Questions: Which Definition of Safety Culture is best? How is Safety Culture is Assessed? How is Safety Culture Enhanced? How Can we obtain a deeper understanding of the concept of culture?
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